Equity is a frequently stated justification for government involvement in the health care market. This is often taken to mean directly providing all segments of the population with a wide range of government-operated health services at no cost: free universal care. Yet a look at the record suggests that this goal all too often remains elusive, especially in poor countries; that governments in fact serve only some of the population; and that the people served are disproportionately concentrated among the better-off. When this happens, government health services, far from promoting equity, work against it. The purpose of this chapter is to illustrate that there are many ways for governments to pursue the goal of ensuring that the poor receive adequate, affordable services through alternative approaches to resource allocation and purchasing. The first section summarizes the information known about the distribution of benefits from government health services across social groups in order to document the regressive pattern that now frequently exists and the need for significant changes in approach if the poor are to benefit. The second and third sections illustrate the kinds of changes that might be considered.
Public-Private Mix
This article tells a story of Nancy (not her real name), who every month travels to Zimbabwe to stock up on Marvelon family planning pills distributed at hospitals‚ clinics and pharmacies through the Family Planning Council of Zimbabwe. She smuggles them back into South Africa‚ where she sells them at a healthy profit to other Zimbabweans who for various reasons don’t want the contraceptive pills dispensed in South African clinics. Nancy’s suppliers are hospital staff in Zimbabwean hospitals who sell the pills to her for R5 a blister pack. If she runs short of stock‚ she buys packets for R10 from a “wholesale” supplier in Johannesburg who also illegally imports the pills from Zimbabwe. Nancy says she has a 100 customers a month in Springs alone‚ and she sells the packets for R20 to bulk buyers or R30 to individuals. By contrast‚ Marvelon tablets were reported to be sold for about R130 per 28 tablets in Johannesburg pharmacies
Kenya’s post election violence has led to the founding of RescueBnB – a community with the mission to map the locations of those in need of shelter and connect them with volunteer hosts. With a core team of volunteers, a web developer set up the pro bono website, and Kenyans have spread the word on social media. Within 48 hours of this, they had assembled more than 100 volunteers across the country and had arranged multiple home stays with vetted hosts. To date, RescueBnB has supported 800 people across Kenya, and team members say that’s just the start. RescueBnB has since begun crowdfunding to provide care packages as well as to cover medical expenses. Its partnerships with community organizations and religious groups helped it reach more individuals, and companies stepped in to assist. A supermarket chain welcomed shoppers to drop off donations, and a boda boda (motorbike) delivery company volunteered to get the donations into the hands of people who needed them.
This report explores the shift from privatisation to corporatisation of urban water services in developing countries. The author calls for the water justice movement to adjust its strategy to take this into account. Corporatisation reform implies the implementation of commercial neoliberal management approaches within public sector water utilities. The author argues that the strategy of the water justice movement has largely focused on privatisation and that it needs to direct more attention towards resisting corporatisation.
Privatisation is being pushed by international governance institutions, the governments that control them, and the corporations that lobby both groups, even though the dangers that privatisation entails can seriously - and permanently - harm the livelihoods of the world's poorest people. The position of "privatise first and ask questions later" and the naïve confidence in the processes and outcomes of market reform have imposed hardship on precisely the groups those organisations are entrusted to protect. It is time to shift the burden of proof from those who question risky solutions to those who propose them, says this article.
The Bill & Melinda Gates Foundation has given a grant of US$7 million over five years to the American Cancer Society to lead and coordinate the African Tobacco Control Consortium, a global coalition of public health-oriented organisations focusing on using evidence-based approaches to stem the tobacco epidemic in Africa. According to the International Agency for Research on Cancer, much of the rise in cancer in Africa can be attributed to widespread tobacco use and exposure to secondhand smoke. Tobacco is the leading cause of preventable death in the world, and according to the World Health Organization, if current trends continue, tobacco use will cause one billion deaths worldwide during this century. As the managing organisation, the Society will collaborate with consortium partners to implement an ambitious tobacco control program across the 46 countries of sub-Saharan Africa. The overall goal will be to reduce tobacco use in these countries by implementing proven strategies at the national and local level.
Medicins Sans Frontiers (MSF) argues in this article that big pharmaceutical companies are charging too much for their vaccines used in the developing world. Price disclosures by GlaxoSmithKline (GSK) and Johnson & Johnson show that these companies have been selling some vaccines at premiums of up to 180%. According to MSF, GSK and Pfizer are selling 30 million doses of pneumococcal vaccines annually to GAVI at a reduced price of US$3.20 through a scheme called Advance Market Commitment, but are also each getting a subsidy of US$215 million. Emerging country suppliers like India’s Serum Institute have said they could sell similar pneumococcal vaccine products for US$2 a dose – a 40% reduction on the GSK and Pfizer price. Serum Institute said recently that if they had not faced patent restrictions, the vaccine could have been available by 2012 – now it is not expected until 2015. Technology transfer and product development grants to low-cost suppliers are being supported by the Bill and Melinda Gates Foundation, but these sums are dwarfed by the Advance Market Commitment subsidy to Big Pharma. MSF calls on GAVI to start thinking about more affordable vaccines and calls on government donors to pressurise GAVI to foster competition and to push for products especially adapted for developing countries.
In the current environment of shrinking global and domestic resources for health care, there is an overwhelming pressure to achieve financial sustainability in the health sectors of developing countries. Within this context, there seems to be increasing acceptance of the view that individuals need to contribute to some of the costs of public health care through charges such as user fees and other cost-recovery mechanisms. This paper looks at the implications of user fees for women's utilization of health care services, based on selected studies in Africa. Lack of access to resources and inequitable decision-making power mean that when poor women face out-of-pocket costs such as user fees when seeking health care, the cost of care may become out of reach. Even though many poor women may be exempt from fees, there is little incentive for providers to apply exemptions, as they too are constrained by restrictive economic and health service conditions. If user fees and other out-of-pocket costs are to be retained in resource-poor settings, there is a need to demonstrate how they can be successfully and equitably implemented. The lack of hard evidence on the impact of user fees on women's health outcomes and reproductive health service utilization reminds us of the urgent need to examine how women cope with health care costs and what trade-offs they make in order to pay for health care.
This paper from Reproductive Health Matters looks at the implications of user fees for women's utilization of health care services, based on selected studies in Africa. Lack of access to resources and inequitable decision-making power mean that when poor women face out-of-pocket costs such as user fees when seeking health care, the cost of care may become out of reach. Even though many poor women may be exempt from fees, there is little incentive for providers to apply exemptions, as they too are constrained by restrictive economic and health service conditions. If user fees and other out-of-pocket costs are to be retained in resource-poor settings, there is a need to demonstrate how they can be successfully and equitably implemented.
Major public health funders have alighted upon an industry-favoured approach of guaranteeing certain prices to industry to make vaccines available to least-developed country markets. The pilot project, the AMC Approach, announced on 12 June, provides nearly US$3 billion to make (presumably patented) vaccines against pneumococcal disease available sooner to the world’s poorest countries. There will be a commitment by industry to continue offering the vaccines at “lower and sustainable” prices after the funding runs out, the Global Alliance for Vaccines and Immunization (GAVI) said. The current pneumococcal vaccine is sold for more US$70 per dose in industrialised countries, while the new project will make the ‘long term’ price for developing countries US$3.50, GAVI added. It hopes to assist up to 60 of the world’s poorest countries to introduce these vaccines by 2015, well ahead of the time it might take without subsidising industry. A World Health Organization working group is set to discuss the issue from 29 June to 1 July.